The prevalence of underfive diarrhea in Somali Regional State, Ethiopia is one of the highest in the country. This study attempted to examine the multiple factors associated with underfive diarrhea and how they might influence its prevalence in Jigjiga, Somali regional state, Ethiopia.
Bizuneh et al BMC Pediatrics (2017) 17:182 DOI 10.1186/s12887-017-0934-5 RESEARCH ARTICLE Open Access Factors associated with diarrheal morbidity among under-five children in Jigjiga town, Somali Regional State, eastern Ethiopia: a cross-sectional study Hailemichael Bizuneh1* , Fentabil Getnet2, Beyene Meressa2, Yonatan Tegene3,1 and Getnet Worku1 Abstract Background: The prevalence of underfive diarrhea in Somali Regional State, Ethiopia is one of the highest in the country This study attempted to examine the multiple factors associated with underfive diarrhea and how they might influence its prevalence in Jigjiga, Somali regional state, Ethiopia Methods: A community based cross-sectional study was conducted from February 15 to 28, 2015 Multistage sampling technique was used to collect data from 492 mothers via household survey A pre-tested, structured questionnaire was used to collect data through face-to-face interview Ethical clearance was obtained before data collection Stepwise multivariable logistic regression was used to calculate adjusted odds ratios Results: The two weeks prevalence of under five diarrhea in Jigjiga town was 14.6% Up on multivariable analysis, maternal educational level of primary school and above was found to be protective against childhood diarrhea [AOR: 0.227(0.100–0.517)] whereas, unavailability of water [AOR: 2.124(1.231–3.664)] and lack of hand washing facility [AOR: 1.846(1.013–3.362)] were associated with diarrhea Conclusion: Poor water supply, lack of hand washing facilities and lack of formal maternal education were associated with underfive diarrhea in the study area Improved access to water supply along with environmental health intervention programs designed to promote good hygiene behavior could be of paramount importance to alleviate burden of childhood diarrhea Keywords: Underfive, Diarrhea, Factors, Hygiene, Jigjiga, Ethiopia Background Diarrhea is one of the leading infectious causes of morbidity and mortality in underfive children [1, 2] In 2015, it was estimated that 1.3 million deaths were caused by diarrheal diseases, of which 499,000 were underfive children [3] Eventhough decline in diarrheal diseases is reported [4] Sub-sahran Africa, including Ethiopia, remains one of the highly affected regions [5–8] The underfive mortality rate in Ethiopia, 88 per 1000, indicates that the effort towards reduction of underfive * Correspondence: hailemichaelbiz@gmail.com Epidemiology and Biostatistics Unit, Department of Public Health, College of Medicine and Health Sciences, Jigjiga University, Jigjiga, Somali Regional State, Ethiopia Full list of author information is available at the end of the article mortality in Ethiopia is still a long way ahead if the country is to achieve the Millennium Development Goal target of reducing the underfive mortality rate by two-thirds between 1990 and 2015 In 2010, in Ethiopia, diarrhea was responsible for 8% of all under-5 mortality and 13% of morbidity amongst under five children The proportion of children with diarrhea for whom advice or treatment was sought from a health care provider was only 32% [9, 10] According to Ethiopian Demographic and Health Survey data for under-5 mortality, Somali regional state reported 93 deaths per 1000 live births and two weeks prevalence of diarrhea was 19.5%, which is the third highest in the country next to Gambella and Benishangul regional states In Somali region, 54.4% of underfive © The Author(s) 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated Bizuneh et al BMC Pediatrics (2017) 17:182 children did not receive any form of treatment for diarrheal morbidity [10] In Ethiopia, various strategies have been implemented to reduce child mortality from diarrhea The Health Sector Development Program IV (2010/11–2014/15), which is a policy implementation strategic document that guides the development of sub national plans and sets the rule of engagement in the health sector, aimed to decrease under-five mortality rate from 101/1000 live births to 68/1000 In doing so, the Integrated Management of Childhood Illness approach, has been implemented as a major strategy Despite the effort, underfive child mortality in the country remains one of the highest in sub-sahran Africa [11, 12] Sociodemographic, household, environmental, and host characteristics play an important role in determining risk and recovery from diarrheal episodes Many of the risk factors for contracting diarrheal illnesses are associated with poor socioeconomic conditions such as: lacking access to safe water and sanitation, poor hygiene practices, unsafe human waste disposal, limited access to health care, education, poor diet and housing conditions [2, 8, 13] So far, few studies have been conducted to identify factors associated with underfive diarrhea in Ethiopia, but a study conducted in Somali Regional State and specifically Jigjiga town is lacking As Somali region has the third highest underfive diarrheal morbidity and mortality rate in the country, a study which addresses the topic is much needed This study attempted to examine the prevalence and factors associated with underfive diarrhea in Jigjiga, Ethiopia Methods This study was a community based cross-sectional study conducted from February 15–28, 2015 Jigjiga is the capital town of Somali Regional State located in the eastern part of Ethiopia The population of the town is estimated to be 159,300 The population is mainly of Somali extraction and most residents are Muslim There is one referral and one zonal hospital, and two health centers in town Sample size was computed based on single population proportion formula assuming 95% confidence interval, 5% margin of error, prevalence (P) of 19.5% (two weeks prevalence of diarrhea among children under age five in Somali Regional State, Ethiopia) [10], a design effect of (since multistage cluster sampling was used) and a non-response rate of 10% which gave a final sample size of 530 A multistage sampling technique was used including Kebeles (administrative sub divisions of town) as firststage units, and Ketenas (non-administrative sub divisions of kebeles) as second-stage units, and households as third-stage units First, of the total 10 kebeles in the Page of town, kebeles were selected by lottery method Then, ketenas were chosen from each of the kebeles The number of ketenas included was proportionally allocated to the size of the kebeles Since the number of underfive children residing in the selected ketenas was not available, a census was conducted in all the selected ketenas to have a sampling frame Based on this sampling frame obtained from the census, the final sample size of 530 was proportionally allocated among the ketenas Systematic random sampling was used within each ketenas to select households for interview In households with more than one under five index children or more than one mother or caregiver, lottery method was used to choose one Two revisits to a household were made for respondents unavailable at the time of data collection Inclusion criteria for the study participants were being an index underfive child, and a mother or care giver who is permanent resident of the town Operational definitions Diarrhea – the presence three and more loose or liquid stools per day within two weeks period prior to survey Dirt floor: floor made of earth, sand or dung Non-dirt floor – floor made of wood planks, palm/ bamboo, parquet/polished, vinyl or asphalt strips, ceramic tiles or cement Hand washing: the physical removal of microorganisms from the hands using soap (plain or antimicrobial) and running water Improved water source: piped water, piped water to yard/plot, public tap or stand pipe, protected dug well and bottled water Unimproved water sources: unprotected dug well, tanker-truck, surface water (river, pond and stream) Proper solid waste disposal – burying or storing in a container and disposing in designed site Improper solid waste disposal – burning, open field disposal Improved liquid waste disposal – flush toilet, flush/ pour to pit latrine, ventilated improved pit latrine and pit latrine with slab Unimproved liquid waste disposal – flush to elsewhere, pit latrine without slab, bucket and no facility Hand washing at critical times – washing hands before and after cooking foods, after latrine use, and before feeding child The outcome variable was diarrhea and independent variables were composed of socio demographic variables, household and environmental, hygiene behavior and child feeding practices A questionnaire adapted from World Health Organization (Core questions on drinking water and sanitation for household surveys) [14] composed of Bizuneh et al BMC Pediatrics (2017) 17:182 closed-ended questions was used in preparation of the instrument The final questionnaire was translated to Somali language and back to English language to check for consistency The questionnaire was pretested on 5% of the total sample size, i.e 27 mothers of underfive children who resided in a Kebele outside the study area Finally a pretested, structured questionnaire was used to conduct face-to-face interviews Additional file Data collectors proficient in the local Somali language were trained by the researchers On-field supervision of data collectors was carried out Data was entered, cleaned and analyzed using Statistical Package for Social Sciences Descriptive statistics was used to present results Crude and adjusted odds ratio with 95% confidence interval were also calculated in univariate and multivariable logistic regressions In order to identify independent factors associated with the outcome, variables significantly associated on univariate analysis at a cut off point p value 0.3 were put in to multivariable model for further analysis Backward stepwise regression was implemented to identify final adjusted odds ratios of independent factors associated with diarrhea at a cut-off point p-value 0.05 Ethical consideration All caregivers underwent informed consent for participation in the study Ethical clearance was obtained from the Institutional Review Board of Jigjiga University, Directorate of Research, Publication and Technology Transfer Results Out of the total of 530 mothers and underfive children targeted for the study, 492 mothers were interviewed The mean age of mothers was 28.6 (±6.57) years, and 146 (29.7%) mothers had no formal education Close to one-half (52.6%) of the households had a family size fewer than five with a mean of (±2.06) Almost all (97.6%) of households used protected water sources such as public standpipes Hand washing stand was not present in most (77.2%) of the households In 117 (23.8%) of the households water was drawn from storage containers by dipping In most (64.5%) of households latrines were shared with one or more neighbors Out of which, 141 (44.3%) were shared with more than five households Majority (94.3%) of the toilet facilities were improved The mean age of index children was 22.53 (±1.48) months Most (65.3%) of children were currently breast feeding, and 443 (90.4%) started complementary food after the age of six month Hand washing at critical time was self-reported by 330 (67.1%) of mothers The two weeks prevalence of diarrhea was 14.6% [Table 1] Factors associated with underfive diarrhea Main variables which were significantly associated with underfive diarrhea upon univariate analysis were: lack of Page of maternal education [COR: 0.227(0.100–0.517)], bigger family size [COR: 1.719(1.025–2.885)], lack of water [COR: 2.128 (1.263–3.585)], lack of hand washing stand [COR: 2.195(1.284–3.752)], latrine sharing [COR: 0.548(0.305–0.987)], drawing water by dipping [COR: 2.119(1.049–4.281)], child age groups 6–11 month [COR: 0.184(0.095–0.357)] and 12–23 months [COR: 0.408(0.212–0.787)] After backward stepwise multivariable regression, variables significantly associated with the outcome variable were: lack of formal education of mothers, unavailability of water, and lack of hand washing facility Children of mothers with primary education and above were less likely to have diarrhea [AOR: 0.227(0.100–0.517)] In houses where water was not available all the time, the odds of diarrhea among children was doubled [AOR: 2.124(1.231–3.664)] Presence of hand washing stand was a significant predictor as children in households with no hand washing stand were 1.846 times more likely to have diarrhea [AOR: 1.846(1.013–3.362)] [Table 2] Discussion This study identified socio-demographic and environmental factors associated with diarrhea among underfive children in the study area Diarrhea was significantly associated with lack of formal maternal education, poor water supply and lack of hand washing facilities In this study, two weeks prevalence of diarrhea among underfive children was 14.6% This prevalence is relatively lower as compared to findings of studies done in other parts of Ethiopia which reported higher prevalences such as: Nekemte (28.9%), Eastern Ethiopia (22.5%), Sheko district (25%), Gilgel Gibe research centre (30%) and West Gojam (18%) [15–19] This might be attributed to differences in socio demographic and environmental factors As the studies were conducted in various parts of the country, important factors such as provision basic hygienic services which might strongly affect underfive diarrhea differ across settings For instance, the latrine coverage in Nekemte town (91.8%) [15] is lower than that of Jigjiga’s (97.1%) and hand washing at critical times in Sheko was reported to be 61.5% [17] which is also lower than that of Jigjiga’s (67.1%) Among socio-demographic variables studied, maternal education was found to be an independent predictor of diarrhea Children of educated mothers were protected against diarrhea as compared to children of mothers with no formal education This finding is consistent with studies conducted in Ethiopia, Uganda and Afghanistan where mothers’ education, especially at post-secondary level, reduced the probability of occurrence of diarrhea [17–22] This might be due to the fact that mothers who had formal education are prone to have more awareness on good hygiene behaviours, safe handling of water, Bizuneh et al BMC Pediatrics (2017) 17:182 Page of Table Characteristics of children under age five, Jigjiga town, 2015 Variable Frequency Percent Primary care giver’s characteristics Age 15–24 146 29.6 25–34 234 47.6 35–49 112 22.8 Educational status Table Characteristics of children under age five, Jigjiga town, 2015 (Continued) Ownership of latrine Private 174 35.5 Shared 318 64.5 Shared with how many households (n = 318) 5 141 44.3 Toilet facility No education 146 29.7 Improved 479 97.3 Primary and above 346 70.3 Non-improved 13 2.7